Provider Demographics
NPI:1134133200
Name:WALLACE, ROBERT DUNCAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:DUNCAN
Last Name:WALLACE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:R
Other - Middle Name:DUNCAN
Other - Last Name:WALLACE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2972 DEVONSHIRE CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-2526
Mailing Address - Country:US
Mailing Address - Phone:801-486-7940
Mailing Address - Fax:
Practice Address - Street 1:2972 DEVONSHIRE CIR
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-2526
Practice Address - Country:US
Practice Address - Phone:801-486-7940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT65-1481212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTE00002Medicare UPIN